Friday, May 27, 2016

The dramatic increase in
the prevalence of autism spectrum disorder (ASD) among children indicates that
a correspondingly large number of youth will be transitioning into adulthood in
the coming years. Investigating social participation of young adults with ASD
is important given that social participation is an indicator of life quality
and overall adaptive functioning. A study using data from the National Longitudinal Transition
Study 2 examined rates of participation in social activities among young adults
who received special education services for ASD, compared to young adults who
received special education for intellectual disability, emotional/behavioral
disability, or a learning disability.

According to the study,
young adults with ASD were significantly more likely to never see friends,
never get called by friends, never be invited to activities, and be socially
isolated. Nearly 40 percent of young adults with ASD never saw friends and half
were not receiving any phone calls or being invited to activities. Researchers
found that 28 percent had no social contact at all. The social struggles of
young people with ASD were also significantly more pronounced than those of
other disability groups. For example, while almost one-third of those with ASD
qualified as socially isolated because they never received telephone calls or
went out with friends, fewer than 10 percent of individuals with intellectual
disability and only 2 to 3 percent of people with emotional disturbance or
learning disabilities fell into this category.

“Difficulty navigating the
terrain of friendships and social interaction is a hallmark feature of autism,”
said Paul Shattuck of WashingtonUniversity who coauthored the study. “Nonetheless, many
people with autism do indeed have a social appetite. They yearn for connection
with others. We need better ways of supporting positive social connection and
of preventing social isolation.”

This study indicates that
there are growing numbers of adolescents and young adults with ASD in need of
substantial support. In fact, the lack of services available to help young
adults with ASD transition to greater independence has been noted by researchers
for a number of years and has become an increasingly important issue as the
prevalence of ASD continues to grow and as children identified with ASD reach
adolescence and adulthood. The focus of intervention/treatment must shift from
remediating the core deficits in childhood to promoting adaptive behaviors that
can facilitate and enhance ultimate functional independence and quality of life
in adulthood. This includes new developmental challenges such as independent
living, vocational engagement, postsecondary education, and family support.

Wednesday, May 4, 2016

The DSM-5 criteria for Autism Spectrum
Disorder (ASD) include
restricted and repetitive patterns of behavior (RRB) as a core diagnostic feature, together with
the domain of social communication and social interaction deficits. Recent
evidence suggests that restricted and repetitive behaviors may differentiate
children who develop autism spectrum disorder (ASD) by late infancy. A study
published in the Journal of Child Psychiatry and Psychology found that
children who show several repetitive behaviors at their first birthday have
nearly four times the risk of autism of children who don’t show repetitive
behaviors.

Researchers collected
parent-report data (Repetitive Behavior Scales-Revised) for 190 high-risk
toddlers and 60 low-risk controls from 12
to 24 months of age. Forty-one high-risk children were classified with ASD at
age 2. Profiles of repetitive behavior were compared between groups. The study
found that the profiles for children diagnosed with ASD differed significantly
from high- and low-risk children without the disorder on all measures of
repetitive behavior. Toddlers with ASD showed significantly higher rates of
repetitive behavior across at the 12-month time point. Repetitive behaviors
were significantly associated with adaptive behavior and socialization scores
among children with ASD at 24 months of age, but were largely unrelated to
measures of general cognitive ability.

These findings suggest
that as early as 12 months of age, a broad range of repetitive behaviors are
highly elevated in children who go on to develop ASD. While some degree of
repetitive behavior is essential to typical early development, the extent of
these behaviors among children who develop ASD appears highly atypical. The
study supports earlier findings that repetitive behaviors may be among the
earliest-emerging signs of autism. It also points to new avenues of inquiry.
While the search for early social deficits has received substantial attention
from researchers, ritualistic, repetitive behaviors have largely been
neglected. This is unfortunate because repetitive behaviors are often easier
for a parent to notice than the absence of a social behavior. Parents of
individuals with ASD also report that restricted and repetitive behaviors are
one of the most challenging features of ASD due to their significant
interference with daily life. Likewise, they can impede learning and
socialization by decreasing the likelihood of positive interactions with peers
and adults. Given the importance of restricted and repetitive (RRB) behavior, clinicians and practitioners should give increased attention to
the assessment and presence of this behavior in screening and assessment as an
early indicator and consider their impact on the psychological well-being of
individuals with ASD.

Restricted and Repetitive behavior (RRB) should be included as a core domain in a comprehensive
developmental assessment. Although broad-based measures
such as the Autism Spectrum Rating Scales (ASRS; Goldstein & Naglieri,
2010) and the Social Responsiveness Scale (SRS-2; Constantino & Gruber,
2012) incorporate scales and treatment clusters assessing stereotypical
behaviors, sensory sensitivity, and highly restricted interests, there are parent/caregiver
questionnaires that focus solely on restricted and repetitive behaviors and
provide a more complete understanding of the impact of RRB on adaptive functioning.
The most commonly used are the Repetitive Behavior Scale-Revised (RBS-R;
Bodfish, Symons, Parker, & Lewis, 2000) and the Repetitive Behavior
Questionnaire-2 (RBQ-2; Leekam et al., 2007). Both cover a wide range of
repetitive behaviors and were designed as a quantitative index of RRB. Individuals
who have marked deficits in social communication, but whose symptoms do not
meet the RRB criteria for ASD, may be evaluated for social (pragmatic)
communication disorder (SCD).Adapted from A Best Practice Guide to Assessment and Intervention for Autism Spectrum Disorder in Schools (2nd Edition).

Tuesday, May 3, 2016

Impairment in
social reciprocity is the core, underlying feature of ASD. Socialization
deficits are a major source of impairment, regardless of cognitive or language
ability and do not decrease with development. In fact, distress often increases
as children approach adolescence and the social milieu becomes more complex. Research
evidence suggests that when appropriately planned and systematically delivered,
social skills instruction has the potential to produce positive effects in the
social interactions of children with ASD. Both the National Professional Development Center on

Autism (NPDC) and the National Autism Center (NAC) have identified social
skills training/instruction as an evidence-based intervention and practice.

Commonly used approaches include individual
and group social skills training, providing experiences with typically
developing peers, and peer-mediated social skills interventions, all targeting
the core social and communication domains. Child-specific social skills
interventions frequently include (a) general instruction to increase knowledge
and develop social problem solving skills, (b) differential reinforcement to
improve social responding,(c) structured social skills training programs, (d) adult-mediated
prompting, modeling, and reinforcement, and (e) various behavior management
techniques such as self-monitoring.

A study appearing in the Journal of
Autism and Developmental Disorders adds to research database suggesting
that social interactive training is an effective and promising technique for
promoting communication and social skills in youth with autism. The study examined the efficacy and durability of the UCLA PEERS Program, a
parent-assisted 14-week social skills group intervention for more capable
adolescents on the autism spectrum. In a series of 90-minute weekly sessions the
students were taught to interact in real-world social situations through role
playing and homework assignments. The teens’ parents also attended sessions to
learn how to appropriately coach their kids at home. Results indicated that
teens receiving PEERS significantly improved their social skills knowledge,
social responsiveness, and overall social skills in the areas of social
communication, social cognition, social awareness, social motivation,
assertion, cooperation, and responsibility, while decreasing autistic
mannerisms and increasing the frequency of peer interactions. Independent
teacher ratings revealed significant improvement in social skills and assertion
from pre-test to follow-up assessment. Examination of the strength of
improvement indicated maintenance of gains in nearly all domains with
additional treatment gains at a 14-week follow-up assessment. “This is exciting
news,” commented Elizabeth Laugeson, an assistant clinical professor of
psychiatry at the University of California, Los Angeles who led the study. “It
shows that teens with autism can learn social skills and that the tools stick
even after the program is over, improving their quality of life and helping them
to develop meaningful relationships and to feel more comfortable within their
social world.”

Monday, May 2, 2016

There
is robust research to suggest that 70 to 80 percent of children with ASD meet
diagnostic criteria for one or more co-occurring (comorbid) disorders and 40 to
50 percent meet criteria for two or more. A Comorbid disorder is
defined as a condition that co-occurs with another diagnosis so that both share
a primary focus of clinical and educational attention. The most prevalent comorbid conditions are mood disorders, anxiety
disorders, attention-deficit/hyperactivity disorder, disruptive behavior disorders, and chronic tic disorders, all which
contribute to overall impairment.

Internalizing Problems

Studies have consistently
reported an association between ASD and internalizing symptoms, in particular,
anxiety and depression. A bidirectional association has been identified between
internalizing disorders and autistic symptoms. For example, both a higher
prevalence of anxiety disorders has been found in ASD and a higher rate of
autistic traits has been reported in youth with mood and anxiety disorders.
Individuals with ASD also display more social anxiety symptoms compared to
typical individuals, even if these symptoms were clinically overlapping with
the characteristic social problems of ASD. In addition, there is some evidence
to suggest that adolescents and young adults with ASD show a higher prevalence
of bipolar disorders as compared to controls.

Depression is one of the
most common comorbid conditions observed in individuals with ASD, particularly
higher functioning youth. A study of psychiatric comorbidity in young adults
with ASD revealed that 70% had experienced at least one episode of major
depression and 50% reported recurrent major depression. Although another
documented association is with obsessive-compulsive disorder (OCD), it is
difficult to determine whether observed obsessive-repetitive behaviors are an
expression of a separate, comorbid OCD, or an integral part of the core
diagnostic features of ASD (i. e., restricted, repetitive patterns of behavior,
interests, or activities).

Externalizing Problems

An association between ASD
and attention-deficit/hyperactivity disorder (ADHD) and other externalizing
problems (i. e., oppositional defiant disorder) have been reported. Studies
have found that children with ASD in clinical settings present with
co-occurring symptoms of ADHD with rates ranging between 37% and 85%. Although
there continues to a debate about ADHD comorbidity in ASD, research, practice
and theoretical models suggest that co-occurrence between these conditions is
relevant and occurs frequently. For example, case studies suggest that ADHD is
a relatively common initial diagnosis in young children with ASD. It is also
important to note that a significant change in the DSM-5 is removal of the
DSM-IV-TR hierarchical rules prohibiting the concurrent diagnosis of ASD and
ADHD. When the criteria are met for both disorders, both diagnoses are given.

Other Comorbidities

Tourette Syndrome (TS) and
other tic disorders have been found to be a comorbid condition in many children
with ASD. A Swedish study showed that 20% of all school-age children with ASD
met the full criteria for TS. There also appears to be a higher incidence of
seizures in children with autism compared to the general population. The
comorbidity of ASD and psychotic disorders has received some research
attention. A study of children with ASD who were referred for psychotic
behavior and given a diagnosis of schizophrenia showed that when psychotic
behaviors were the presenting symptoms, depression and not schizophrenia, was
the likely diagnosis. Thus, individuals with ASD may present with
characteristics that could lead to a misdiagnosis of schizophrenia and other
psychotic disorders.

Conclusion

Children and youth with
ASD frequently have comorbid conditions, with rates significantly higher than
would be expected from the general population. The most common co-occurring
diagnoses are anxiety and depression, attention problems, and disruptive behavior
disorders. The core symptoms of ASD can often mask the symptoms of a comorbid
condition. The current challenge for practitioners is to determine if the
symptoms observed in ASD are part of the same dimension (i. e, the autism
spectrum) or whether they represent another condition. Although various
psychometric instruments, such as clinical interviews, self-report
questionnaires and checklists, are widely used to assist in diagnosis, these
tools are designed and standardized to identify symptoms in the general
population, and may not be appropriate and valid for use with ASD. Likewise,
their administration may be problematic in that individuals with ASD may have
difficulties in sustaining a reciprocal conversation, reporting events, and
lack an understanding and empathy for the feeling of others. Nevertheless,
comorbid problems should be assessed whenever significant behavioral issues
(e.g., inattention, impulsivity, mood instability, anxiety, sleep disturbance,
aggression) become evident or when major changes in behavior are reported.
Co-occurring conditions should also be carefully investigated when severe or
worsening symptoms are present that are not responding to intervention or
treatment.

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